Healthcare Provider Details

I. General information

NPI: 1437291226
Provider Name (Legal Business Name): DOUGLAS J MONTGOMERY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 BLUE ASH RD
CINCINNATI OH
45242-6822
US

IV. Provider business mailing address

237 WILLIAM HOWARD TAFT, PHYS DIV 2ND FL, CBO2-3, ATTN: CREDENTIALING
CINCINNATI OH
45219-2906
US

V. Phone/Fax

Practice location:
  • Phone: 513-792-7445
  • Fax: 513-791-4042
Mailing address:
  • Phone: 513-792-7445
  • Fax: 513-791-4042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.000196
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: